(PA school Q4) Radiology > 7.1: Nontraumatic skeletal abnormalities > Flashcards

7.1: Nontraumatic skeletal abnormalities Flashcards

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1
Q

Orthopedic imaging: Descr Orthogonal views

A

“One view is no view”
Views that are at 90-degree angles to each other
Localize abnormalities in 3D
Visualize more bone

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2
Q

Is XR useful for orthopedic imaging?

A

Cannot visualize entire circumference of bone
Not useful for ortho soft-tissue findings
(except significant swelling)

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3
Q

Descr the 2 modes of Circumferential Imaging in orthopedics

A

1) CT: Good at differentiating bone cortex from medulla
Used to confirm fractures that are equivocal on XR
2) MRI: Excellent for Bone marrow, Soft tissues, & Confirming fractures
-overall MRI is very great

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4
Q

List the parts of a bone

A

1) Diaphysis; Shaft of the bone
2) Epiphysis: Ends of the bone
3) Metaphysis: Region where diaphysis joins epiphysis
4) Physis (children): Growth plate

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5
Q

List the parts of a joint

A

1) Joint capsule: Protects and stabilizes joint
2) Articular cartilage: Cushions subchondral bone
3) Synovial membrane: Secretes synovial fluid
4) Synovial fluid; Lubricates joint

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6
Q

Bones are continuously undergoing remodeling; explain

A

Osteoclasts resorb old/damaged bone
Osteoblasts form new bone
Depends on viable blood supply
Bone mineral is a reflection of metabolic health

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7
Q

Bone Responds to mechanical forces; explain what this includes

A

Weight bearing
Muscles/tendons
Use (or disuse)

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8
Q

Diseases that alter bone density can be categorized according to what 2 things?

A

Bone density: increased or decreased
Extent: diffuse or focal changes

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9
Q

Desc Recognizing increased bone density

A

1) Sclerosis
Abnormal hardening
(whiteness)
2) Loss of distinction between cortex and medulla: Medulla density abnormally increased

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10
Q

Bone metastatic disease: What are the 3 groups of cancers that metastasize to bone?

A

osteoblastic, osteolytic, and mixed

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11
Q

Osteoblastic Metastatic Disease: What is it?

A

Disease of increased bone density
Abnormally increased osteoblastic activity
Deposition of new bone
Localized or diffuse

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12
Q

Osteoblastic Metastatic Disease: Where does it occur?

A

1) Lesions distal to elbow or knee are uncommon; if present, cancer is likely to be widespread
2) Focal disease: sclerotic lesions most common in vertebrae, ribs, pelvis, humeri, and femurs

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13
Q

Osteoblastic Metastatic Disease: What are the 2 main parts of bone it may affect?

A

1) Bone medulla: Punctate, amorphous, sclerotic lesions
2) Bone cortex: Lead to periosteal reaction

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14
Q

What are some causes of periosteal rxn?

A

Bone healing in response to fracture or chronic stress
Hematoma
Osteomyelitis
Cancer
Others

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15
Q

1) What is the periosteum?
2) What is a periosteal rxn?

A

1) Periosteum = membrane covering bones
2) New bone formation due to abnormal stimulus; a nonspecific radiographic finding

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16
Q

Desc bone scans for skeletal metastases

A

1) Highly sensitive
2) Not specific; E.g. fracture, osteomyelitis
-Positive bone scan require follow up studies; XR, CT, MRI

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17
Q

Avascular Necrosis:
1) What is it also called? What is it?
2) Where is it more common?

A

1) Aka ischemic necrosis, aseptic necrosis, osteonecrosis
Loss of vascular supply leads to cellular death and eventual collapse
2) More common in bones with poor collateral blood supply: Scaphoid in wrist, femoral head

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18
Q

What are some causes of AVN?

A

Trauma
Cushing disease
Exogenous steroids
Legg-Calve-Perthes
Lupus
Sickle-cell
Polycythemia vera

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19
Q

What does AVN look like on XR?

A

1) Devascularized bone appears denser
More sclerotic than remained of bone
Especially noticeable in femoral and humeral heads
2) Crescent sign: Linear subchondral fractures

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20
Q

Descr AVN of humeral head on imaging

A

“Snow-capping”
“Snow on a mountain top”
Increased density of “top” of humeral head

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21
Q

When osteonecrosis occurs in epiphysis, it is called “____________ necrosis”

A

avascular

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22
Q

Osteonecrosis occurs in metaphysis or diaphysis; describe osteonecrosis

A

“bone infarct”
Ischemic death of bone marrow
Same risk factors as AVN
Usually asymptomatic

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23
Q

What is the Most sensitive method for detecting AVN? What does it show?

A

MRI: “Decreased fatty marrow signal”

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24
Q

Paget’s Disease:
1) What is it?
2) What causes it?

A

1) Chronic disease of abnormal bone remodeling
Increased bone formation and resorption (net formation)
Increased bone density
Denser bone = mechanically inferior
More susceptible to fractures
2) Idiopathic, possibly related to chronic viral infection

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25
Decreased Bone Density: 1) What is it? 2) What is the issue w this?
1) Bone loss in medullary cavity Accentuation of the cortex stands out relative to decreased medullary density 2) Low bone density Predisposes to fractures
26
Osteoporosis: When does it occur?
1) Usually due to age-related decrease in bone density Begins around 45 2) Postmenopausal Increased osteoclastic activity Estrogen possibly preserves osteoblasts by inhibiting apoptosis Decreased estrogen = increased osteoblastic apoptosis = decreased osteoblastic activity
27
What are some other causes/ risk factors for osteoporosis? Why?
1) Steroids: Reduce ability to absorb calcium 2) Cushing’s disease: Increased cortisol (Stimulates osteoclasts? Blocks calcium?) 3) Inadequate activity: Weight bearing activities preserve bone and stimulate chondrocytes 4) Chronic alcoholism: Affects calcium metabolism Interferes with vitamin D production Increases parathyroid hormone
28
Describe DEXA scans
1) Duel-Energy X-ray Absorptiometry Most accurate way of measuring bone density 2 x-ray beams of differing energy Difference in penetration is measured
29
Hyperparathyroidism: What is it/ what does it do?
Excess PTH secretion Stimulates osteoclasts (increased bone resorption)
30
Hyperparathyroidism: What are the radiographic findings?
1) Overall decreased bone density 2) Subperiosteal bone resorption: Especially radial side of middle phalanges of index and middle fingers 3) Acroosteolysis (acro- refers to tip) 4) Brown tumor: Not a neoplasm, area of increased osteoclast activity
31
Name a site besides the fingers that's a Common site of bone resorption in hyperparathyroidism
Distal clavicle erosion Increased distance between distal clavicle and acromion
32
Osteolytic Metastatic Disease: 1) What is it? 2) When is it noticable?
1) Metastatic deposits replace marrow Leads to focal destruction of bone 2) Not noticeable on XR until there is 50% bone loss in medullary cavity MRI is much more sensitive
33
Descr Osteolytic Metastatic Disease on imaging
1) “Expansile” or “Soap-bubbly” “Expansile lytic lesion with internal trabeculations” 2) More likely to be malignant if there is no periosteal reaction (benign lesions more likely to have periosteal reaction) 3) Pedicle sign / winking owl sign: Pedicles more likely to be destroyed due to blood supply
34
Myeloma (Myelo- = bone marrow or spinal cord) 1) How common is it? 2) What does it look like? 3) Give an example
1) Most common primary bone malignancy in adults 2) Early disease appears like diffuse, severe osteoporosis 3) Solitary form: Soap-bubble expansile lesion
35
Descr disseminated myeloma/ Multiple myeloma aka plasma cell myeloma
“Punched out, lytic lesions” Uniform in size Too numerous to count Well-marginated
36
Osteomyelitis: 1) What is it? 2) What are the imaging findings?
1) Focal destruction of bone most commonly due to Staph. aureus 2) Focal cortical bone destruction Periosteal new bone formation Soft-tissue swelling
37
Osteomyelitis: Where can it extend into?
Can extend into joint space (septic arthritis) More common in adults
38
Osteomyelitis: What is a unique imaging method?
Indium-labelled WBC scan: -Patient’s WBCs removed -Tagged with radiotracer -Injected into patient -Scan shows site(s) of increased uptake
39
Joint Diseases: Descr the role of imaging
1) Imaging is important in diagnosis and management of joint diseases 2) Many joint diseases are initially diagnosed on imaging Arthritis XR is the study of choice for detect arthritis
40
What are the 3 main categories of arthritis? Describe each
1) Hypertrophic Bone formation at the site of the involved joint 2) Erosive Underlying inflammation Characterized by erosions Tiny, irregularly shaped lytic lesions 3) Infectious Joint swelling, osteopenia, and cortical destruction
41
Descr Primary osteoarthritis AKA DJD
Most common arthritis Wear and tear of articular cartilage Most common joints: hips, knees, hands
42
What are the 4 signs of primary osteoarthritis? Descr each
1) Joint space narrowing: Due to cartilage destruction 2) Sclerosis: Chondrocytes stimulated as joint space narrows 3) Osteophytes: Bone outgrowths from overactive chondrocytes 4) Subchondral cysts: Hollow cyst forms when bones hit each other
43
Charcot Arthropathy: 1) What is it also called? 2) What causes it? 3) What are its characeristics?
1) AKA Charcot joint, neuropathic joint 2) Autonomic disruption leading to bone resorption, fragmentation, and microfractures 3) Most dramatic joint destruction of any arthritis “Extensive subchondral sclerosis” “Fragmentation”
44
CPPD: 1) What does it stand for? 2) What causes it?
1) Calcium pyrophosphate deposition disease 2) CPP crystals deposited in joints; especially in wrist TFCC and knee menisci “Chondrocalcinosis” = Think CPPD first
45
Rheumatoid Arthritis: 1) What joints does it affect? 2) What is the initial study of the choice?
1) Proximal joints of hands and wrists Usually bilateral and symmetric 2) XR is initial study of choice
46
RA: Descr how it affects the hands
1) CMC, MCP, PIP 2) Eventual subluxations leading to deformities Swan-neck and boutonniere
47
How does RA affect the larger joints?
Significant joint space narrowing with minimal sclerosis
48
Gout: 1) What causes it? 2) How long does it take to see on XR?
1) Calcium urate crystal deposition in joints 2) Long latent period between symptoms and XR changes 5-7 years, so NOT a radiographic diagnosis
49
Gout: List its 3 primary characteristics
1) Monoarticular: MTP of great toe 2) “Rat-bite” erosions: Sharp juxtaarticular erosions 3) Tophi: Collections of urate crystals in soft tissues -Olecranon bursitis
50
Descr Psoriatic Arthritis
1) 25% of long-standing psoriasis patients develop PA Will usually first have skin and nail changes for years 2) Polyarticular Small joints of hands Especially DIP joints “Pencil-in-cup” deformity Phalangeal resorption causes telescoping
51
Infectious Arthritis: 1) What is it also called? 2) What causes it?/ what are the 2 categories?
1) AKA septic arthritis 2) Seeding into synovial membrane from infection source Pyogenic: Staph and gonococcoal organisms Nonpyogenic: Mycobacterium tuberculosis -IV drug use, steroids, joint prostheses, trauma
52
What will you see on XR of infectious arthritis?
Relatively insensitive to early findings Still the initial study Destruction of articular cartilage and long segments of adjacent cortex
53
Nonpyogenic infectious arthritis: 1) What usually causes it? 2) What does it cause?
1) Usually from M. tuberculosis, spreads from lung via blood 2) Gradual loss of joint space, late destruction, monoarticular severe osteoporosis
54
Infectious Arthritis: 1) What will confirm it? 2) What imaging is sensitive?
1) Aspiration will confirm 2) MRI is used extensively in diagnosing septic joints
55
List the parts of the spine
1) Cervical spine: 7 vertebrae -Lordotic curve 2) Thoracic spine: 12 vertebrae (rib-bearing) -Kyphotic curve 3) Lumbar spine: 5 vertebrae -Lordotic curve 4) Sacrum: 5 vertebrae (fused)
56
The _________ vertebrae have a transverse foramen which is the opening for vertebral artery and vein
Cervical
57
Describe the intervertebral discs
Nucleus pulposis Central gelatinous portion Annulus fibrosus Surrounds nucleus
58
How long does the spinal cord go?
Extends from medulla oblongata to conus medullaris Terminates L1-L2 then branches into cauda equina
59
How are nerves numbered?
1) C1-C7: Exit above the vertebrae 2) C8: Exits C7-T1 3) Remaining: Exit below their respectively numbered vertebrae
60
What do the spinal ligaments do?
Traverse the spine, hold vertebrae together
61
Describe an XR – lumbar spine oblique and what it detects
1) “Scotty dog view” 2) Detects pars interarticularis defect (spondylolysis)
62
Nontraumatic Spinal Abnormalities: What are some of the many causes?
Disc herniation Disc degeneration Facet arthritis Fractures Spinal stenosis Malignancy Infection Strain
63
MRI is ideally the study of choice for spinal pathology; why? What are some downsides?
-Soft tissue, marrow, spinal cord, nerves, discs -Expensive, not as widespread as CT Cannot be used with pacemakers, stimulators, clips Anxiety/panic due to claustrophobia
64
Degenerative Disc Disease: What is it?
Progressive loss of intervertebral disc height Normal degenerative process Exacerbated by other factors
65
Degenerative Disc Disease: What will you see on XR?
1) Disc space narrowing 2) Endplate sclerosis 3) Osteophytes 4) Vacuum disc phenomenon “Disc air” Nitrogen released as disc desiccates Late sign of DDD
66
Degenerative Disc Disease: What will you see on MRI?
1) Water content of nucleus decreases 2) Lower signal intensity on T2
67
Describe Herniated Discs in each section of the spine
1) Cervical spine May produce radiculopathy and myelopathy C4-5, C5-6, C6-7 2) Thoracic Not common, stabilized by rib cage 3) Lumbar spine Radiculopathy (sciatica) and back pain L3-4, L4-5, L5-S1
68
Herniated Discs: 1) What incr risk of bulging? 2) What can these lead to?
1) Trauma or degeneration of annular fibers 2) Annular rupture can allow nucleus to herniate through weakened area of posterior longitudinal ligament -Usually posterolateral herniation -Nerve root compression -Can extrude into spinal canal
69
Spinal Stenosis: 1) What is it? 2) What causes it? Give examples
1) Narrowing of spinal canal or neural foramina 2) Caused by soft-tissue and/or bony abnormalities Ligament hypertrophy Bulging discs Osteophytes Facet arthropathy Burst Fractures Spondylolisthesis
70
Facet Arthropathy: 1) What is it? 2) What can it cause? 3) What does it often occur with?
1) Osteoarthritis of the facet joints, i.e. True synovial joints -Cartilage, synovial lining, synovial fluid 2) Facet overgrowth/hypertrophy/arthropathy can protrude into neural foramina 3) Often occurs with DDD
71
DISH: 1) What is it? 2) Who does it usually occur in? 3) What is a common symptom?
1) Calcifications at ligament insertions “Enthesophytes” Bridging ossification of at least 4 contiguous vertebral bodies; anterior or posterior 2) Usually in men over 50 3) Back stiffness is common No/mild pain?
72
Ankylosing Spondylitis: 1) What is it? 2) What does it cause? 3) What is a key lab finding in these pts? 4) What is the hallmark PE finding?
1) Chronic progressive arthritis 2) Inflammation and eventual fusion of SI and facet joints Starts in SI joints and ascends 3) Almost always positive for HLA-B27 Protein on surface of WBCs 4) Sacroiliitis
73
Discitis / Osteomyelitis: 1) What is it almost always assoc with? 2) What does it cause?
1) Diskitis (infection of the disk) is almost always associated with osteomyelitis of the adjacent vertebrae Staph aureus is usually the cause 2) Destruction of vertebral endplates
74
Spinal Malignancy: 1) What is common and why? 2) What is a main finding?
1) Rich blood supply in posterior spine, so metastatic deposits are common Especially from breast and lung cancer 2) Pathologic compression fractures Especially in posterior aspect (osteoporotic fractures are in anterior aspect)
75
Spinal Malignancy: What study do you do? Why?
Bone scan is the study of choice Scans entire body, widely available, inexpensive Very sensitive, not specific Requires follow up testing
(PA school Q4) Radiology
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